The persistent gap in health-care coverage between low- and high-income workers in Washington State: BRFSS, 2003-2007

Objectives

We examined the disparities in health-care coverage between low- and high-income workers in Washington State (WA) to provide support for possible policy decisions for uninsured workers.

Methods

We examined data from the WA Behavioral Risk Factor Surveillance System 2003–2007 and compared workers aged 18–64 years of low income (annual household income <$35,000) and high income (annual household income ≥$35,000) on proportions and sources of health-care coverage. We conducted multivariable logistic regression analyses on factors that were associated with the uninsured.

Results

Of the 54,536 survey respondents who were working-age adults in WA, 13,922 (25.5%) were low-income workers. The proportions of uninsured were 38.2% for low-income workers and 6.3% for high-income workers. While employment-based health benefits remained a dominant source of health insurance coverage, they covered only 40.2% of low-income workers relative to 81.5% of high-income workers. Besides income, workers were more likely to be uninsured if they were younger; male; Hispanic; less educated; not married; current smokers; self-employed; or employed in agriculture/forestry/fisheries, construction, and retail. More low-income workers (28.7%) reported cost as an issue in paying for health services than did their high-income counterparts (6.7%).

Conclusion

A persistent gap in health-care coverage exists between low- and high-income workers. The identified characteristics of these workers can be used to implement policies to expand health insurance coverage.Socioeconomic disparities in health and health care have increased since the 1990s.^1–3 In the U.S., while employment-based insurance is the major source of paying for health care,^4,5 the increase in health insurance premiums has outpaced workers'' earnings and inflation rates. The average cost of health insurance rose 9.6% annually from 2003 to 2007, a rate that was much higher than the overall rate of inflation (2.8%) or the increase in workers'' earnings (2.9%) during the same time period (author calculation based on a 2007 report by the Kaiser Family Foundation⁴). Rising costs impose a greater burden on low-income workers than their higher-income counterparts because low-income workers are less likely to work for a company that offers health insurance coverage.^5–9 Without employer-sponsored health insurance, few low-income workers are able to afford private coverage on their own.^7,10 Further, most of these low-income workers are ineligible for public health insurance programs.^6,10,11 This ineligibility is because in most states, income eligibility is lower for parents than for children and for those adults without dependent children.¹⁰Many factors affect the likelihood of an individual having health insurance and the source of that coverage. Work status and income play a dominant role in determining an individual''s likelihood of having health insurance.^5,7–9,12 Uninsured workers were found disproportionately in the agriculture, construction, and trade industries,^5,8,9,13 and in the farming, operators/fabricators/labors, and services sectors.^8,9 Uninsured workers also were more likely to be self-employed,^8,14 to work for small firms,^{5,7–9,13,15,16} and to be employed as part-time or temporary workers.^5,14,17,18 Socioeconomic characteristics related to lack of health-care coverage include being male, younger, from a racial/ethnic minority group, less educated, and in a low-wage or low-income job.^5,8,12,14,19 Consequently, uninsured workers were less likely to have a usual source of care and receive timely preventive services, and more likely to experience a decline in overall health.^{7,9,12,20–22}Although national uninsured trends are well documented, published work concurrently considering workers'' socioeconomics, industry, and occupation characteristics in Washington State (WA) is lacking. In an effort to expand the current knowledge on uninsured workers in WA and provide support for possible policy decisions, we conducted a multivariate analysis on health-care coverage comparing low-income workers with high-income workers by pooling the five-year WA Behavioral Risk Factor Surveillance System (BRFSS) data. Because most of the uninsured come from working families and have low incomes,^4,6,10 we identified characteristics of workers who did not have health-care coverage and examined how low-income workers have fared in health-related outcomes. The analysis presents trends, examines multiple factors that affect health insurance coverage, and discusses policy implications. We hypothesized that even after controlling the multiple factors associated with being uninsured, less health-care coverage and increased health-care costs would impose a greater burden for low-income workers and families.     

Disparities in Influenza Vaccination Coverage Among Women with Live-Born Infants: PRAMS Surveillance During the 2009–2010 Influenza Season

Objectives

Vaccination during pregnancy significantly reduces the risk of influenza illness among pregnant women and their infants up to 6 months of age; however, many women do not get vaccinated. We examined disparities in vaccination coverage among women who delivered a live-born infant during the 2009–2010 influenza season, when two separate influenza vaccinations were recommended.

Methods

Pregnancy Risk Assessment Monitoring System (PRAMS) data from 29 states and New York City, collected during the 2009–2010 influenza season, were used to examine uptake of seasonal (unweighted n=27,153) and pandemic influenza A(H1N1)pdm09 (pH1N1) (n=27,372) vaccination by racially/ethnically diverse women who delivered a live-born infant from September 1, 2009, through May 31, 2010.

Results

PRAMS data showed variation in seasonal and pH1N1 influenza vaccination coverage among women with live-born infants by racial/ethnic group. For seasonal influenza vaccination, coverage was 50.5% for non-Hispanic white, 30.2% for non-Hispanic black, 42.1% for Hispanic, and 48.2% for non-Hispanic other women. For pH1N1, vaccination coverage was 41.4% for non-Hispanic white, 25.5% for non-Hispanic black, 41.1% for Hispanic, and 43.3% for non-Hispanic other women. Compared with non-Hispanic white women, non-Hispanic black women had lower seasonal (crude prevalence ratio [cPR] = 0.60, 95% confidence interval [CI] 0.55, 0.64) and pH1N1 (cPR=0.62, 95% CI 0.57, 0.67) vaccination coverage; these disparities diminished but remained after adjusting for provider recommendation or offer for influenza vaccination, insurance status, and demographic factors (seasonal vaccine: adjusted PR [aPR] = 0.80, 95% CI 0.74, 0.86; and pH1N1 vaccine: aPR=0.75, 95% CI 0.68, 0.82).

Conclusion

To reduce disparities in influenza vaccination uptake by pregnant women, targeted efforts toward providers and interventions focusing on pregnant and postpartum women may be needed.Pregnant women are at increased risk for complications from influenza and are more likely than the general population to be hospitalized due to respiratory illness during influenza season.^1–4 Seasonal vaccination can reduce morbidity and mortality associated with seasonal influenza.^1,2 While the influenza vaccine recommendations for pregnant women date back to the 1960s, it was in 2004 that the American College of Obstetricians and Gynecologists (ACOG) and the Advisory Committee on Immunization Practices (ACIP) recommended that women be vaccinated with the inactivated influenza vaccine any time during pregnancy.^5–7 Historically, the national estimates showed that, of the adult groups recommended to receive seasonal vaccination, pregnant women had the lowest coverage prior to the 2009–2010 influenza season.^7–9 Research has shown that there are racial/ethnic and economic disparities in vaccination coverage among adults. In general, vaccination coverage is lower among non-Hispanic black and Hispanic women than among non-Hispanic white women and women of lower socioeconomic status.^10–16 For pregnant women in particular, coverage prior to the 2009–2010 influenza season was less than 30%.^8,9Because influenza can be especially severe during pregnancy, pregnant women in particular were at increased risk of severe disease and mortality from pandemic influenza A(H1N1)pdm09 (pH1N1) virus infection.¹⁷ During the 2009–2010 influenza season, both the inactivated trivalent seasonal and monovalent pH1N1 vaccinations were recommended for pregnant women.^17,18 Pregnant women were deemed a priority group for the pH1N1 vaccine due to high morbidity and mortality associated with pH1N1 infection within this group. Monovalent pH1N1 vaccine was purchased by the federal government and made available to the public at no cost. Additionally, the monovalent vaccine was made available later than the trivalent seasonal influenza vaccine.Given the recommendation of vaccination for pregnant women and the importance of preventing morbidity and mortality from influenza, we examined disparities in vaccination uptake by pregnant women with recent live-born infants who participated in the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. The rationale for examining data from the 2009–2010 influenza season was to learn about vaccination coverage of a vulnerable population (i.e., pregnant women) during the pandemic.^19,20 Research questions guiding the analysis included (1) What are the differences in vaccination coverage among racial/ethnic groups of pregnant women? and (2) Are there differences by race/ethnicity in the patterns of vaccination uptake for the two influenza vaccinations offered during the 2009–2010 influenza season?     

Accuracy of Parental Reports of Children's HPV Vaccine Status: Implications for Estimates of Disparities, 2009–2010

Objectives

Since the introduction of the human papillomavirus (HPV) vaccine in 2006, there have been considerable efforts at the national and state levels to monitor uptake and better understand the individual and system-level factors that predict who gets vaccinated. A common method of measuring the vaccination status of adolescents is through parental recall. We examined how the accuracy of parents'' reports of their daughters'' HPV vaccination status varied by social characteristics.

Methods

Data were taken from the 2009–2010 National Immunization Survey (NIS)-Teen, which includes a household interview and a provider-completed immunization history. We evaluated concordance between parents'' and providers'' reports of teens'' HPV vaccine initiation (≥1 dose) and completion (≥3 doses). We assessed bivariate associations of sociodemographic characteristics with having a concordant, false-positive (overreporting) or false-negative (underreporting) report, and used multinomial logistic regression to estimate the independent impact of each characteristic.

Results

In bivariate analyses, concordance of parent-reported HPV vaccine initiation was associated with each of the sociodemographic characteristics investigated. In regression models, self-reported nonwhite race, lower household income, and lower education level of the teen''s mother were associated with a higher likelihood of having a false-negative parental report than a concordant report.

Conclusion

Our results indicate that, while estimates of overall coverage based on parental report may be unbiased, the differences in the accuracy of parental report could result in misleading estimates of disparities in HPV vaccine coverage.Human papillomavirus (HPV) vaccination has been promoted as an effective public health intervention to prevent cervical cancer.¹ Recommended for girls aged 11 and 12 years and previously unvaccinated women up to age 26 years,² it is administered in three doses during a period of six months. Recently, the recommendations have been updated to also include boys aged 11 and 12 years.³The effectiveness of HPV vaccination for reducing cervical cancer depends upon uptake. Not surprisingly, there have been considerable efforts to monitor uptake and better understand the individual and system-level factors that predict who gets vaccinated.^4–7 The validity of the results from these studies, however, rests with the measurement of vaccination status.A common method of measuring vaccination status is through parental recall. For example, the National Health Interview Survey asks parents about their awareness of the vaccine for HPV, whether their child had received the shot, and, if so, how many doses the child had received.⁸ Other national and regional surveys similarly rely on parental/guardian reports.^5,7,9,10HPV vaccination uptake has been lower than was initially hoped.^5,8,11 Additionally, substantial attention has been paid to social group differences in initiation and completion of the three-dose series. Results have been mixed, with some researchers concluding that uptake and vaccination completion rates are lower among girls from disadvantaged social groups^7,12,13 and others reporting equal or higher rates for girls from lower socioeconomic backgrounds or from minority cultural groups.^7,8Systematic measurement error resulting from using parental reports of vaccine status may affect the validity of estimates. Two types of error may be particularly important. First is the issue of memory or recall bias.^14,15 Respondents may forget whether their child had the HPV vaccine or the number of doses received. However, given the media attention to the HPV vaccine¹⁶ and the three-dose vaccination schedule, this issue may be less of a problem than for other vaccines.A second source of measurement error is social desirability bias, or the tendency of survey respondents to give answers that they think are more socially acceptable. In general, in studies of health behaviors, people will say they engaged in socially sanctioned health behaviors (e.g., preventive care) when they did not.¹⁷ The case of HPV vaccine is somewhat different from many preventive health behaviors because there may be competing social norms. Most parents in studies of social attitudes understand the link between HPV vaccination and cervical cancer.¹⁸ Thus, the socially desirable answer is to indicate that their child has been vaccinated. However, some parents express concern that HPV vaccination is associated with sexual activity,¹⁸ which could theoretically lead parents to underreport vaccination status if they are concerned that interviewers will think that their child is sexually active.Reporting error at the population level is of concern because it could bias estimates of uptake and completion of the vaccination series. It is also important to look at systematic differences between social groups (e.g., race/ethnicity and socioeconomic status [SES]) in measuring the accuracy of vaccination status. If such systematic differences exist, estimates of whether there are disparities in HPV vaccine uptake will be distorted.Dorell and colleagues examined whether parents over- or underreport vaccination status.¹⁹ Using data from the 2008 National Immunization Survey-Teen (NIS-Teen), which has the advantage of collecting both provider and parental reports of vaccine status, they found that, while agreement between household and provider report for the HPV vaccine was highest overall of any of the adolescent vaccines (Kappa=0.76 for initiation among parents reporting from recall only), disagreement tended to be in the direction of underreporting. Similarly, in a study comparing the reports of mothers and girls with medical records, Stupiansky et al. found that mothers underreported the vaccination status of their daughters.²⁰Recently, Ojha et al. compared the accuracy of adult proxy recall for teens'' HPV vaccine status with the use of household immunization records using the 2010 NIS-Teen.²¹ The findings indicated that sensitivity of adult proxy recall tended to be lower than specificity, and that adult proxy respondents who were the mothers (vs. the fathers), non-Hispanic white, older, and more educated tended to provide more accurate reports. Overall, they conclude that adult recall of vaccine initiation and use of shot cards “have reasonable accuracy for classifying HPV vaccination status.”²¹ However, the researchers did not examine (1) whether sociodemographic factors are associated with over- or underreporting and (2) the implications of reporting error for estimates of vaccination status for specific subgroups.Using data from the NIS-Teen, the data used by the Centers for Disease Control and Prevention to generate national estimates, we build on the existing literature focusing on the accuracy of parental reports of HPV vaccine status by sociodemographic characteristics that are markers of advantage and disadvantage. We examined (1) concordance between parental and provider reports for initiation of HPV vaccine and completion of the recommended three doses and (2) whether both under- and overreporting by parents are associated with social characteristics.     

Sun-seeking behavior to increase cutaneous vitamin D synthesis: when prevention messages conflict

Objectives

The public has long been encouraged to engage in sun-safe practices to minimize exposure to sunlight, the major cause of nonmelanoma skin cancer. More recently, some have advocated unprotected sun exposure to increase cutaneous synthesis of vitamin D as a way to promote health. We assessed the net result of these conflicting messages.

Methods

In a cross-sectional survey in 2007, questionnaires were mailed to participants of an ongoing cohort study in Washington County, Maryland. The study population consisted of 8,027 adults (55% response rate).

Results

Thirty percent of respondents were aware that unprotected sun exposure increased endogenous vitamin D levels. Among those who were aware of this benefit, 42% reported going out into the sun to increase vitamin D levels. Sun-seeking to increase vitamin D production did not significantly differ according to self-reported personal history of skin cancer, but was significantly higher among women, older age groups, those with less education, and vitamin D supplement users.

Conclusion

A substantial proportion of respondents reported sun-seeking behavior expressly to increase endogenous vitamin D levels. The message about sun exposure and vitamin D is reaching the general public; however, this finding poses challenges to skin cancer prevention efforts.Among all human malignancies, skin cancers are by far the most common^1,2 and in the U.S. are among the most costly.³ With exposure to solar ultraviolet (UV) radiation as the major cause of nonmelanoma skin cancer,² prevention strategies have emphasized sun avoidance and skin-protection behaviors such as use of sunscreen and skin-protective clothing. Longstanding public education campaigns have sought to reduce sunlight exposure with the goal of reducing skin cancer incidence rates.^4,5In addition to being the primary cause of human skin cancer, solar UV radiation is also responsible for stimulating cutaneous vitamin D synthesis. In turn, vitamin D is critical for calcium homeostasis and skeletal maintenance.⁶ The observation that hypovitaminosis D was common in general medical inpatients, even in those with vitamin D intakes exceeding the recommended daily allowance and those without apparent risk factors for vitamin D deficiency, led to the hypothesis that the general population may have suboptimal levels of vitamin D.^6,7 As understanding of this topic progressed, it gradually gave rise to the observation that sun avoidance, with the goal of preventing skin cancer, may compromise vitamin D sufficiency.⁷ For bone health, consensus has been achieved concerning the definition of vitamin D deficiency (<25 nanograms per milliliter [ng/ml] 25-hydroxyvitamin D [25(OH)D]). For overall health, however, the general definition of vitamin D insufficiency varies.^6,7Both interest and concern regarding vitamin D has increased as evidence has accumulated that its potential health benefits may extend beyond skeletal health. The public''s concerns about vitamin D insufficiency have been raised as studies reporting health benefits have received media coverage, touting the health benefits of the “sunshine vitamin.”^4,8,9 Based on the premise that vitamin D is important to overall health and well-being, some reports have extolled the benefits of regular sun exposure^6,10 and even tanning bed use.¹⁰ For example, vitamin D deficiency and decreased exposure to sunlight have been hypothesized to increase the risks of many common cancers, type 1 diabetes, rheumatoid arthritis, and multiple sclerosis.^6,10 Based on these potentially wide-ranging health benefits of vitamin D, some have suggested that the benefits of sun exposure to increase cutaneous vitamin D synthesis may outweigh the risks (e.g., skin cancer) associated with unprotected exposure to solar UV radiation.^6,10The importance of understanding the public''s perceptions of these issues is accentuated by the fact that the actual relationship between sun exposure and cutaneous vitamin D synthesis and metabolism is complex and incompletely understood even by the scientific community. In a study of highly sun-exposed (average weekly sun exposure of 29 hours) young adults in Hawaii, approximately one-half had 25(OH)D concentrations <30 ng/ml, and 9% had concentrations <20 ng/ml.¹¹ Under tightly controlled experimental conditions among adults in the United Kingdom, UV radiation exposure of approximately 35% of the total skin surface area at doses similar to summer sunlight three days a week for 13 minutes per day resulted in 25(OH)D concentrations of ≥20 ng/ml (“sufficient”) in 10% and concentrations of ≥32 ng/ml (“optimal”) in 74% of the adults.¹² Thus, in addition to factors affecting UV radiation dose, such as season of year, time of day, latitude, altitude, and atmospheric conditions,^13,14 results such as these suggest there is considerable inter-individual variability in cutaneous vitamin D synthesis in response to sunlight. The determinants of these inter-individual differences in vitamin D synthesis and metabolism are undoubtedly complex and multifactorial, but contributors appear to be factors such as age, race, vitamin D supplement use, calcium intake, body mass index (BMI), skin type, and genetic characteristics.^7,8,13,15 Advances are being made in understanding how genetic variants contribute to inter-individual differences in vitamin D status; for example, the results of a recent genome-wide association study revealed variants at three loci that were associated with a significantly higher likelihood of vitamin D insufficiency.¹⁶Further complicating matters, some researchers currently recommend lower-level sun exposure of approximately 15 minutes per day with face and hands exposed,^13,17 but the evidence described previously adds uncertainty with respect to the extent to which this level of sun exposure results in the desired increase in circulating vitamin D concentrations. Furthermore, application of this recommendation is controversial given that solar UV radiation is the major cause of skin cancer.² Additionally, even those who engage in sun-protective behaviors (e.g., sunscreen use) may not apply the sunscreen in a manner that would prevent vitamin D synthesis to the degree theoretically possible on the basis of the sun protection factor.^14,15,18The small but growing body of evidence on this topic indicates that lack of attention to this issue may lead to further escalation in the incidence of skin cancer. Few studies have examined the impact on the general population of the mixed medical and media messages that range from sun avoidance for skin cancer prevention to the sun-seeking, pro-vitamin D message. We addressed this evidence gap by describing the prevalence of (1) awareness of unprotected sun exposure to increase vitamin D and (2) the extent to which concerns about vitamin D may be influencing sun exposure behaviors.     

Legionnaires' Disease and Associated Comorbid Conditions as Causes of Death in the U.S., 2000–2010

ObjectiveRecent U.S. outbreaks of Legionnaires'' disease (LD) underscore the virulent nature of this infectious pneumonia. To date, only a paucity of literature has described the mortality burden of LD. This study updates LD mortality using U.S. multiple-cause-of-death data from 2000–2010.MethodsWe calculated crude and age-adjusted rates for LD mortality for age, sex, race, state, Census region, and year. We conducted Poisson regression to assess seasonal and temporal trends. We generated matched odds ratios (MORs) to describe the association between LD-related deaths and other comorbid conditions listed on the death certificates.ResultsWe identified a total of 1,171 LD-related deaths during 2000–2010. The age-adjusted mortality rate remained relatively static from 2000 (0.038 per 100,000 population, 95% confidence interval [CI] 0.031, 0.046) to 2010 (0.040 per 100,000 population, 95% CI 0.033, 0.047). The absolute number increased from 107 to 135 deaths during this period, with adults ≥45 years of age having the highest caseload. Overall, LD mortality rates were 2.2 times higher in men than in women. White people accounted for nearly 83.3% of all LD-related deaths, but the age-adjusted mortality rates for black and white people were similar. Comorbid conditions such as leukemia (MOR=4.8, 95% CI 3.5, 6.6) and rheumatoid arthritis (MOR=5.6, 95% CI 3.3, 9.4) were associated with LD diagnosis on death certificates.ConclusionComorbid conditions that could lead to an immunocompromised state were associated with fatal LD on U.S. death certificates. Characterization of LD mortality burden and related comorbidities has practice implications for clinical medicine and public health surveillance.Legionnaires'' disease (LD) is a severe form of pneumonia that can become fatal in vulnerable individuals.^1–5 The condition is caused by the gram-negative bacterium Legionella pneumophila, a naturally occurring organism found in water.^2,3 The organism is primarily transmitted to humans through inhalation of contaminated aerosolized water droplets. Typical sources of outbreaks include, but are not limited to, hot tubs, hot water tanks, large plumbing systems, decorative fountains, and cooling towers. The pneumophila species is generally not found in car or window air-conditioners.^1–4 To date, no person-to-person transmission has been documented.^1–4,6,7Risk factors that increase susceptibility to LD include advanced age, smoking, chronic lung disease, and having a weak or suppressed immune system.^1–4,6,7 Among individuals with a weakened immunity, those with cancer, diabetes, or kidney failure are particularly at risk. Although human immunodeficiency virus (HIV) infection has been linked to more severe infections, LD is generally not more common among people with HIV/acquired immunodeficiency syndrome (AIDS).^1,8,9 More than 20% of cases in the United States reported to the Centers for Disease Control and Prevention (CDC) each year are travel-related.³ Nosocomial transmissions of LD can be problematic, as at-risk individuals are plentiful and plumbing in hospital facilities is often old.^1,4 Because in-house diagnostic testing is readily available, detection of LD is more likely in the hospital setting.⁴ Currently, CDC recommends urinary antigen assay and a culture of respiratory secretions on selective media as the diagnostic tests of choice for confirming Legionella infection.³Annually, CDC estimates that as many as 18,000 individuals are hospitalized with LD in the U.S.³ However, this number is considered an underestimate, as the disease is often underreported due in part to its diagnostic complexity and its resemblance to other pneumonias with similar symptom presentations.^3,7 Symptoms of LD include cough, shortness of breath, fever, muscle aches, and headaches; they often start shortly after exposure to the bacteria.^1–4,6Recent LD outbreaks in the Veterans Affairs (VA) Medical Center in Pittsburgh, Pennsylvania, and in a retirement community in Ohio affirm the virulent nature of this infection and underscore the importance of the causative infectious pathogen to clinical practice and public health surveillance.^10,11 Based on hospitalizations and treatment data, the annual costs for LD have been estimated at nearly $684 million.¹² Few studies have recently examined LD mortality and its associated comorbid conditions. This study contributes to the closing of this gap in the literature by analyzing the national multiple-cause-of-death (MCD) data to describe the current mortality profile of LD in the U.S., for the period 2000–2010.     

Changes in the relationship between marriage and preterm birth, 1989-2006

ObjectiveMaternal marriage has historically been protective against preterm birth (PTB); however, social norms and behaviors surrounding marriage have changed over time in the United States. We analyzed secular trends in the relationship between marriage and PTB.MethodsWe collected data about all births in Michigan between 1989 and 2006 to assess (1) the relationship between marital status and PTB and moderately PTB risk by year, and (2) the relationship between married and unmarried status and PTB and moderately PTB by year relative to similar marital status in 1989.ResultsAmong nearly 2.4 million births between 1989 and 2006, PTB risk among married mothers increased while risk among unmarried mothers decreased. In adjusted models, married status became less protective against PTB relative to unmarried status over time by year, and was associated with higher risk of PTB over time. Moderately PTB risk increased among both married and unmarried groups, but more so among married mothers.ConclusionOur findings suggest that marriage is becoming less protective against PTB over time. The influence of social factors on risk for adverse birth outcomes is likely dynamic, suggesting that ongoing revisions to our understanding are in order.Defined by the World Health Organization as birth before 37 completed weeks of gestation, preterm birth (PTB) is a major contributor to perinatal and neonatal mortality, serious neonatal morbidity, and moderate to severe childhood disability.¹ In wealthy countries such as the United States, 6%–10% of all births are preterm, and deaths to preterm infants comprise more than two-thirds of all neonatal deaths.²Married status has long been associated with a lower risk of PTB,^1,3,4 as well as other adverse perinatal outcomes including low birthweight,^3,5,6 small-for-gestational-age infants,^3,5,7,8 and fetal and neonatal mortality.⁹ Several factors may explain the relationship between marital status and risk for adverse birth outcomes, including differences between married and unmarried mothers in financial security,^10–12 health-care access,^4,13 social support, and mental health.^14–18The presumed health-promoting effect of marriage has led to its promotion as a positive social construct that may improve the health of populations.^19–22 However, in the past two decades, the role of marriage has changed in North America. Bumpass and Cherlin independently contended that marriage has undergone a “decline in significance” and a deinstitutionalization as a result of a deterioration of the marital norms that shape partners’ social behaviors and a trend toward individuation, personal choice, and self-development.^23,24 It is plausible, therefore, that as norms governing partners’ marital behaviors have deteriorated over time, mechanisms mediating the relationship between marriage and PTB risk may have weakened, thereby altering the relationship between marital status and the risk of PTB. For example, as partners involved in marital relationships become more independent and self-oriented, and therefore invest fewer of their resources (e.g., money, time, and attention) in one another, it follows that the financial and social support afforded married mothers via their marriages may diminish, with plausible downstream effects on maternal mental health and access to health-care services.In addition, the increasing incidence of PTB in wealthy countries in the past two decades has been shown to be partially attributable to the increasing rate of obstetric interventions,²⁵ such as cesarean section and induced labor.²⁶ Compared with unmarried mothers, married mothers have been shown to have more ready access to health services.^4,13 It is possible that a higher rate of later-term obstetric interventions among married vs. unmarried mothers could change the relationship between marital status and PTB over time by increasing the incidence of obstetrically induced PTB among married vs. unmarried mothers.We hypothesized that the apparent protective effect of marriage on risk of PTB has decreased with time as a result of the aforementioned mechanisms. We analyzed secular trends in PTB, very PTB, and moderately PTB risk among married and unmarried mothers over time using data from one U.S. state between 1989 and 2006.     

HIV testing and management: findings from a national sample of Asian/Pacific islander men who have sex with men

Objectives

We examined reasons for and barriers to participating in HIV voluntary counseling and testing for Asian/Pacific Islander (A/PI) men who have sex with men (MSM) in the U.S.

Methods

We collected data between June 2007 and September 2009 in a study known as Men of Asia Testing for HIV, using a cross-sectional community-based participatory design. This national study was conducted in seven U.S. metropolitan cities through a coalition of seven community-based organizations.

Results

Participants included 445 self-identified A/PI MSM aged ≥18 years. Perception of being at risk was the number one reason for testing behaviors. For first-time testers, structural barriers (e.g., language barriers with health professionals) and fear of disclosure (e.g., sexual orientation not known to parents) were deterrents for nontesting in the past. Among previously known HIV-positive men, 22% were not seeing a doctor and 19% were not taking any HIV medications.

Conclusions

HIV testing, care, and treatment policies would be less than optimal without addressing barriers to testing, including stigma related to sexual orientation, among A/PI MSM.Men who have sex with men (MSM) continue to have the highest human immunodeficiency virus (HIV) infection rates in the U.S., with MSM of color being disproportionately affected by the disease.¹ Compared with MSM of other racial/ethnic groups, Asian/Pacific Islander (A/PI) MSM have the highest proportion of acquired immunodeficiency syndrome (AIDS) cases, with a majority of them being non-U.S.-born.^2,3 Research attributes this disparity to low testing rates^4–6 and late diagnosis, which are often associated with advanced AIDS symptoms⁷ as well as late entry into care.^8,9Voluntary counseling and testing (VCT) has been a successful standard of HIV prevention since the emergence of the epidemic in the U.S. and other developed countries.^10–14 This prevention strategy has also been adopted by other developing countries.¹⁵ Nonetheless, the uptake of VCT is still less then optimal.¹⁶ For example, combining multiple datasets from the 2000 to 2005 National Health Interview Surveys, Ostermann et al. found little change in lifetime and past year testing, respectively. However, individuals who perceived higher risks of contracting HIV were more likely to plan for and engage in actual HIV testing.¹⁷Meanwhile, the literature consistently indicates that the stigma of having HIV and/or being a sexual minority is a major barrier or determinant for efficacious or effective prevention, intervention, and treatment, especially among marginalized, vulnerable, or underserved populations.¹⁸ Using a qualitative methodology (i.e., in-depth interview), Yoshioka and Schustack found three major barriers to disclosure of HIV status among a sample of HIV-positive men of Asian descent in the U.S.: (1) protection of family from shame, (2) protection of family from obligation to help, and (3) avoidance of communication regarding highly personal information (including same-sex sexual orientation).¹⁹Collectively, these articles in the literature lend to the postulation that the effectiveness of VCT hinges on at-risk individuals having well-informed information regarding the attitudes, beliefs, and practices of HIV testing.²⁰ Although a small number of cross-sectional studies have been conducted,^6,7,9,21 little to no national data are available addressing HIV testing and HIV management among A/PI MSM. To that end, we used data from a national study of HIV prevention to describe and examine (1) reasons for and barriers to HIV testing among a national sample of A/PI MSM, and (2) care and treatment among those who have tested HIV-positive in the past, by nativity (U.S.-born vs. non-U.S.-born).     

The complex web of health: relationships among chronic conditions, disability, and health services

Objectives

A critical issue in health-care reform concerns how to realign health-care delivery systems to manage medical care services for people with ongoing and costly needs for care. We examined the overlapping health-care needs of two such population groups among the U.S. working-age population (those aged 18–64 years): people with chronic medical conditions and people with disabilities.

Methods

Using the Medical Expenditure Panel Survey (2002–2004), we examined differences in health status, service use, and access to care among and between working-age adults reporting disabilities and/or one or more chronic conditions. We also analyzed people with three key chronic conditions: arthritis, diabetes, and depression.

Results

More than half of working-age people with disabilities reported having more than one chronic condition. Among those with activities of daily living or instrumental activities of daily living limitations, 35% reported four or more chronic conditions at a time. We found considerable variability in access problems and service use depending on how we accounted for the overlap of multiple conditions among people with arthritis, diabetes, and depression. However, disability consistently predicted higher emergency department use, higher hospitalization rates, and greater access problems.

Conclusions

The overall prevalence of chronic conditions among the U.S. working-age population, coupled with the high concentration of multiple chronic conditions among those with disabilities, underscores the importance of reforming health-care delivery systems to provide person-centered care over time. New policy-relevant measures that transcend diagnosis are required to track the ongoing needs for health services that these populations present.As the United States considers dramatic changes in the way its health-care delivery system is organized, two groups merit particular attention: individuals with disabilities and individuals with chronic health conditions. At a time when health-care costs are escalating at an unsustainable pace, both groups consume health-care services at a disproportionately high rate^1–6 while also experiencing less than optimal health outcomes.^7–9 Furthermore, health-care resources are not equitably distributed,¹⁰ calling for substantive changes in the way in which services are provided.The health of people with disabilities gained additional visibility on the national health agenda via the Healthy People 2010 objectives¹¹ and the Surgeon General''s Call to Action to Improve the Health and Wellness of Persons with Disabilities.¹² At the same time, the growing number of adults with chronic conditions has led to a proliferation of disease management programs,^13–17 as well as a substantial body of research describing chronic disease, its consequences, and associated responses.^1,2,9,18,19 What remains less articulated in the scientific literature is that these are actually overlapping groups. While adults with disabilities are likely to have multiple chronic conditions, adults with chronic conditions are likely to develop limitations in functioning or participation, particularly as conditions accumulate over time. In this study, we directly analyzed this overlap, with a focus on health, access to care, and service use in the U.S.Previous research shows that a substantial number of adults have multiple chronic conditions and may also have limitations in activities or functioning. For instance, in 1997, nearly 25% of Medicare beneficiaries had limitations in activities of daily living (ADLs).³ Within this group, the prevalence of cancer, stroke, diabetes, and rheumatoid arthritis was each more than 20%, and the prevalence of hypertension and osteoarthritis was higher than 50%. Treatment of these conditions required up to one health-care visit a week, and these individuals were twice as likely to be dissatisfied with the coordination of their care.²⁰Whether one considers the new medical home initiatives,²¹ obesity reduction,²² disease self-management,²³ prevention of secondary conditions among people with disabilities,²⁴ or any number of further priority items on the nation''s public health agenda,²⁵ there remains a pressing need to quantify the extent of comorbidity in the U.S. population and to clarify its associations with disability. About half of all Americans have at least one chronic condition, and given that roughly half of those individuals actually have more than one such condition at a time, the pursuit of these agenda items may be hampered if approached only one disease at a time.² Furthermore, when individuals accrue limitations in how they function or the activities they can do, additional interventions may be required to assure their access to health-care services, to coordinate the providers involved in their care, or to craft treatment regimens that accommodate their functional needs.²⁶To build upon the existing literature, we analyzed a nationally representative sample of working-age Americans, clarifying the way in which health, access to care, and service use is impacted by a single chronic condition vs. multiple chronic conditions, with or without self-reported disability limitations. As exemplars, we also examined three conditions in greater detail: arthritis, diabetes, and depression. Among the most highly prevalent chronic conditions in the U.S., these three conditions were selected because they potentially result in a wide range of health and functional impacts across different body systems, are accompanied by differing constellations of comorbid conditions, and may require care from providers in differing specialties or settings.^27–29 Thus, we examined the relative contributions of a single primary diagnosis, multiple comorbidities, and disability limitations to several key health-care measures, including access to care, ambulatory visits, hospitalizations, and emergency department (ED) use.While substantial health services research has been conducted on the impact of chronic conditions on older Americans^3,30,31 and children,^32–34 less is known about these phenomena among the working-aged, particularly for people with disabilities. Additionally, the impact of chronic conditions and disability on major life activities, such as school or work, necessarily varies with life course stage. Given the large size of the working-age population, additional concerns regarding their insurance coverage, and their distinct role expectations relative to older adults or children, we limited our analysis to people aged 18–64 years.     

Protecting Newborns by Immunizing Family Members in a Hospital-Based Vaccine Clinic: A Successful Tdap Cocooning Program During the 2010 California Pertussis Epidemic

Objective

Infants are at greatest risk for mortality from pertussis infection. Since 2005, the Advisory Committee on Immunization Practices has recommended a cocooning strategy of vaccinating all close contacts of infants with tetanus, diptheria, and acellular pertussis (Tdap) vaccine to reduce the risk of transmitting pertussis. Difficulties in establishing a complete cocoon have been reported in the literature. We determined whether families of newborns could be fully immunized against pertussis, thereby providing a complete cocoon of protection.

Methods

Tdap vaccine was offered during visiting hours to contacts aged 7 years and older and to postpartum patients who had not received Tdap vaccine during pregnancy. We then conducted retrospective phone interviews with randomly selected mothers (or other family members) to assess vaccination rates. We compared household vaccination rates during intervention and control periods and the demographic factors associated with Tdap vaccination of all members within the households.

Results

During the intervention period, 243 postpartum patients and 1,287 other family members of newborns were immunized, with 84.8% of all family members receiving Tdap vaccination. Seventy-six percent of households reported a complete cocoon. In the control group, 52.2% of all family members received Tdap vaccination, and 29.3% of households had a complete cocoon. In the control group, fewer family members completed Tdap vaccination in the larger households than in the smaller households (p=0.008).

Conclusion

A cocooning strategy can be successfully implemented, such that the majority of newborns leave the hospital with their families fully immunized against pertussis.Pertussis, or whooping cough, remains a serious health concern in the 21st century. Among vaccine-preventable diseases in the United States, pertussis causes the greatest number of infections.¹ Intermittent pertussis epidemics continue to occur, most recently in California (2010)² and Washington State (2012).³ Young children are disproportionately affected by infection with pertussis.^4–6 Among all age groups, infants younger than three months of age account for the vast majority of hospitalizations, serious complications, and deaths.^7,8Protecting this youngest cohort from pertussis remains problematic. An infant''s immune system cannot mount an adequate immune response to currently available vaccine preparations prior to 6–8 weeks of age.⁹ Full antibody protection is generally not acquired until an infant has received three diphtheria, tetanus, and pertussis vaccines at 6 months of age.¹⁰ Thus, the most vulnerable time for disease coincides with the period when an infant is not and cannot be fully immunized.Protecting infants from pertussis by vaccinating family members is a strategy first promoted by the Centers for Disease Control and Prevention in 2005.¹¹ Known as “cocooning,” the concept rests on the fact that family members and other close contacts are the source of infant infections in 76%–83% of cases.^12,13 Despite the theoretical simplicity, cocooning has proven difficult to implement.^14–17 Immunizing mothers alone has been shown to be inadequate in preventing infant pertussis infection.¹⁸ Even with resource-intensive programs, however, cocooning efforts have achieved a full cocoon in fewer than 30% of families.¹⁹We sought to determine whether an outpatient vaccine clinic in the inpatient setting could reach enough family members to create a complete cocoon of protection within households of newborns. Prior to our implementation of a Family Cocooning Clinic, there was no standard protocol within our institution for immunizing family members of newborns.     

Obesity Among Chronically Homeless Adults: Is It a Problem?

Objective

We examined rates of obesity and associated characteristics in the chronically homeless population to explore how a range of factors, including sociodemographics, housing, food source, physical and mental health, and health service use, were related to being overweight or obese.

Methods

We conducted multivariate regression analyses on a community sample of 436 chronically homeless adults across 11 U.S. cities to examine the prevalence of obesity.

Results

The majority (57%) of chronically homeless adults were overweight or obese. Chronically homeless adults who were female or Hispanic appeared to be at particular risk for obesity. There were few differences on physical and mental health by weight group. Although overweight and obese chronically homeless adults were more likely to discuss exercise with a health-care provider, they reported engaging in less exercise than those who were underweight or normal weight.

Conclusion

These findings underscore the need for greater attention to obesity in chronically homeless adults and demonstrate a food insecurity-obesity paradox or poverty-obesity link.Obesity has become a worldwide epidemic.^1–3 In the United States, 34% of adults are obese and 34% are overweight, meaning 68% are either overweight or obese.⁴ Obesity has been linked to various health problems, many of which have high morbidity and mortality, including diabetes, musculoskeletal disorders, cardiovascular disease, pulmonary disorders, and cancer.^3,5 Thus, identifying and intervening with people who are overweight or obese has become important for primary and secondary prevention.^6–8There has been little study of obesity among chronically homeless adults. Homeless adults represent a marginalized, neglected segment of the population and are known to experience poorer physical health than the general population.^9,10 Because adults who are chronically homeless lack a stable, secure residence and often cannot afford regular, healthy meals,^11–13 they are presumed to be underweight. However, this assumption has not been empirically examined, and there is evidence to suggest there may be an obesity problem among the homeless.A nationally representative survey of 1,704 homeless adults and 400 soup kitchens and shelter providers in 20 cities found that 63% of homeless adults reported obtaining meals from soup kitchens and 51% from shelters in a one-week period.¹⁴ Only 17% of soup kitchens, food pantries, and shelters surveyed were working with a nutritionist or dietician. The nutritional value of food served in many soup kitchens and shelters has been found to be low in vitamins and to exceed fat, energy, and protein content recommendations.^15,16A growing literature in the past decade has reported on a food insecurity-obesity paradox, whereby food insecurity, which often results from inadequate economic resources to purchase food, is associated with obesity, which is a consequence of overconsumption of food.^17,18 Many theories have been proposed to explain this correlation, including the low cost of energy-dense foods, binge eating habits as an adaptive physiological response to food scarcity, and childhood poverty leading to obesity in adulthood.^17,19 Related literature has also suggested a poverty-obesity link, finding that populations with high poverty rates and low education levels have the highest obesity rates.^1,20–22Yet the question remains whether there is an obesity problem among chronically homeless adults, and no prior study could be found directly addressing this question. Thus, this study aimed to examine the prevalence of obesity in a multisite community sample of chronically homeless adults and explore how a range of variables known to be related to weight, including sociodemographics, income and insurance, housing, food source, physical and mental health, and health service use, may be related to being overweight or obese.     

Cancer-related disparities and opportunities for intervention in Northern Plains American Indian communities

Objectives

We examined behavioral trends associated with cancer risk and cancer screening use from 1997 through 2006 among American Indians/Alaska Natives (AI/ANs) in the Northern Plains region (North Dakota, South Dakota, Nebraska, and Iowa) of the United States. We also examined disparities between that population and non-Hispanic white (NHW) people in the Northern Plains and AI/ANs in other regions.

Methods

We analyzed Behavioral Risk Factor Surveillance System data from the Centers for Disease Control and Prevention for 1997–2000 and 2003–2006. We used age-adjusted Wald Chi-square tests to test the difference between these two periods for AI/ANs and the difference between AI/ANs and NHW people during 2003–2006.

Results

There was no statistically significant improvement among AI/ANs in the Northern Plains region for behaviors associated with cancer risk or cancer screening use, and there was a significant increase in the obesity rate. The prevalence of binge drinking, obesity, and smoking among AI/ANs in the Northern Plains was significantly higher than among NHW people in the same region and among AI/AN populations in other regions. Although the percentage of cancer screening use was similar for all three groups, the use of sigmoidoscopy/colonoscopy was significantly lower among the Northern Plains AI/ANs than among NHW people.

Conclusion

These results indicate a need for increased efforts to close the gaps in cancer health disparities between AI/ANs and the general population. Future efforts should focus not only on individual-level changes, but also on system-level changes to build infrastructure to promote healthy living and to increase access to cancer screening.American Indians/Alaska Natives (AI/ANs) who live in the Northern Plains region of the United States have disproportionate cancer disparities. In all regions of the country combined, the cancer incidence rate is lower among AI/ANs (368.4 per 100,000 population) than among non-Hispanic white (NHW) people (457.9 per 100,000 population). However, in the Northern Plains, AI/ANs have a higher cancer incidence rate (538.1 per 100,000 population) than do NHW people (464.8 per 100,000 population). Northern Plains AI/AN men and women also have the highest and second highest cancer incident rates, respectively, within the AI/AN population in the U.S.¹ Moreover, Northern Plains AI/ANs have the highest cancer mortality rate among the AI/AN population nationally (275.5 per 100,000 population), a higher rate than for all races combined in the U.S. (200.9 per 100,000 population).² Northern Plains AI/ANs, when compared with their NHW counterparts in the region and in the U.S., have an elevated risk of developing and/or dying from lung, colorectal, breast, cervical, and prostate cancers.^2–7 Liver, kidney, stomach, cervical, and gallbladder cancers that are relatively rare among NHW people are more prevalent among AI/ANs.^8–10 Further, AI/ANs in the Northern Plains and other regions are more likely to be diagnosed at a late stage for breast, cervical, colorectal, and prostate cancers than are NHW people.^4,5,7,8,11About 80% of cancers are attributable to environmental and lifestyle factors.^12,13 Regional variations in cancer risk within the AI/AN population and variations between AI/AN and other population groups may be due in part to differences in behavioral risk factors such as tobacco and alcohol use, lack of physical activity, and obesity.^14–16There is a well-established link between voluntary and involuntary commercial tobacco exposure and cancers of the lung, larynx, oral cavity and pharynx, esophagus, pancreas, bladder, cervix, and gastrointestinal systems, as well as acute myeloid leukemia.^17,18 Chronic alcohol consumption is another important risk factor for the development of various types of cancers, including cancers of the organs and tissues of the respiratory tract and upper digestive tract, liver, colorectum, and breast.^19,20 Excessive and prolonged use of alcohol is a strong risk factor for cancer in the upper aerodigestive tract.^21,22 Excessive alcohol use is also a major risk factor for hepatocarcinogenesis²³ and alcohol-related liver cancer that primarily develops in people with liver cirrhosis resulting from chronic excessive alcohol consumption.¹⁹ Although the risk for alcohol-related colorectal and breast cancer is smaller than for upper aerodigestive tract cancer, alcohol is still likely an important risk factor because of the high prevalence of alcohol use in the U.S.^19,21,24,25 Moreover, synergistic effects of alcohol and smoking have been noted for cancers of the esophagus, head, and neck.^26–29Obese individuals are at higher risk of developing post-menopausal breast cancer; cancers of the endometrium, colon, and kidney; and malignant adenomas of the esophagus.²⁰ Recent studies also suggest that obesity may be linked to other types of cancer, including pancreatic, hepatic, and gallbladder. Possible mechanisms that relate obesity to cancer risk include insulin resistance and chronic hyperinsulinemia (tissue inflammation mediated by adipose tissue), although the underlying mechanisms for the increased cancer risk as a result of obesity are not clearly understood.^20,30Epidemiologic research provides evidence for the effects of physical activity in reducing cancer risk.^31–33 For example, on average, moderate-intensity or greater physical activity can reduce the risk of developing breast cancer by 20%–30%^34–37 and colon cancer by 30%–40%.^31,38 Strong evidence exists to support the theory that a diet high in fruit, vegetables, and fiber-rich foods and low in processed foods and red meats may reduce the risk of developing gastrointestinal cancers (e.g., cancers of the stomach, colon, and rectum).^39–43In 2005, the Northern Plains Comprehensive Cancer Control Program (NPCCCP) was established by the Great Plains Tribal Chairmen''s Health Board (GPTCHB, formerly the Aberdeen Area Tribal Chairmen''s Health Board) to address cancer disparities among AI communities in the four-state Northern Plains region (North Dakota, South Dakota, Iowa, and Nebraska), which is served by the GPTCHB. In 2007, the Northern Plains Tribal Cancer Data Initiative was developed to improve access to cancer data. As part of the initiative, an analysis of the Centers for Disease Control and Prevention''s (CDC''s) Behavioral Risk Factor Surveillance System (BRFSS) data was proposed to evaluate the patterns and trends of behaviors associated with cancer risk and screening behaviors among AI/ANs residing in the four-state Northern Plains region.Our study addressed two questions: (1) Did behaviors associated with cancer risk and screening use among AI/ANs residing in the Northern Plains improve from 1997 through 2006? and (2) What is the extent of the disparities in behaviors associated with cancer risk and cancer screening use among AI/ANs in the Northern Plains, NHW people in the Northern Plains, and AI/ANs in other regions? In this article, we report findings from our analysis of national and regional BRFSS data to answer these questions. In addition, we discuss strategies to reduce cancer disparities in the AI/AN population.     

Assessing the Validity and Reliability of Three Indicators Self-Reported on the Pregnancy Risk Assessment Monitoring System Survey

Objectives

We investigated the reliability and validity of three self-reported indicators from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey.

Methods

We used 2008 PRAMS (n=15,646) data from 12 states that had implemented the 2003 revised U.S. Certificate of Live Birth. We estimated reliability by kappa coefficient and validity by sensitivity and specificity using the birth certificate data as the reference for the following: prenatal participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Medicaid payment for delivery; and breastfeeding initiation. These indicators were examined across several demographic subgroups.

Results

The reliability was high for all three measures: 0.81 for WIC participation, 0.67 for Medicaid payment of delivery, and 0.72 for breastfeeding initiation. The validity of PRAMS indicators was also high: WIC participation (sensitivity = 90.8%, specificity = 90.6%), Medicaid payment for delivery (sensitivity = 82.4%, specificity = 85.6%), and breastfeeding initiation (sensitivity = 94.3%, specificity = 76.0%). The prevalence estimates were higher on PRAMS than the birth certificate for each of the indicators except Medicaid-paid delivery among non-Hispanic black women. Kappa values within most subgroups remained in the moderate range (0.40–0.80). Sensitivity and specificity values were lower for Hispanic women who responded to the PRAMS survey in Spanish and for breastfeeding initiation among women who delivered very low birthweight and very preterm infants.

Conclusion

The validity and reliability of the PRAMS data for measures assessed were high. Our findings support the use of PRAMS data for epidemiological surveillance, research, and planning.The Pregnancy Risk Assessment Monitoring System (PRAMS) is one of the largest state-based surveillance systems of women with live births documenting experiences before, during, and after pregnancy. The data from PRAMS surveys are linked to the birth certificate information. The birth certificate is an important source of data for examining infant health at the state and national levels and is used widely.^1–3 Many studies have examined the reliability and validity of data from the U.S. birth certificate and other data sources such as postpartum surveys, medical records, and registry data.^1–19 Some indicators on the birth certificate are found to be more reliable than others, such as maternal demographics, insurance, and birthweight.^{4,5,7,13,15,19} Birth certificate data have been reported to have lower sensitivity for tobacco and alcohol use;^6,10 birth defects;²⁰ prenatal care;¹¹ and maternal weight gain, medical risks, and obstetric complications,^2,8,9,12,13 although the sensitivity varies by subgroups of women and birth outcomes for many items.^16,17Because PRAMS data are self-reported, it is important to examine the reliability and validity with other population-based data-collection systems such as the birth certificate, which is an established system mandated to assess the health of mothers and babies in the U.S. According to state laws, each live birth must be registered and a birth certificate must be filed. Federal law mandates the national collection and publication of birth certificate data.²¹ A new electronic birth certificate reporting standard was implemented in 2003, replacing the version that had been in place since 1989.²² The 2003 version updated the birth certificate by revising or dropping items and adding new elements with detailed guidance provided on coding data.²³States participating in the Centers for Disease Control and Prevention''s (CDC''s) PRAMS project sample women with recent live-born deliveries using the state birth certificate files. Selected data from the state birth certificate file are linked to the PRAMS survey of women with live-born infants. Some of the measures on the new birth certificate reporting standard are the same as or similar to those on the PRAMS survey. Several studies have compared the validity of measures on PRAMS with birth certificate data, and this study examines additional indicators that had not been assessed previously.^7,18Little has been available on the validity and reliability of information on participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during pregnancy; Medicaid payment for delivery; and breastfeeding initiation in the early postpartum period, comparing PRAMS data with other data sources. WIC and Medicaid are important sources of services for low-income women and, because these data are used to examine research and programming questions, we investigated the reliability and validity of these indicators. The PRAMS data were compared with the birth certificate as the standard because the comparison of PRAMS data might provide insight about improving the accuracy and quality of PRAMS data. In addition, this investigation may provide insight into using both sources of data in concert to maximize the accuracy of information on women and children. Two research questions guided this investigation: (1) What degree of agreement/reliability exists between PRAMS survey responses and the birth certificate on participation in prenatal WIC services, Medicaid payment for delivery, and breastfeeding initiation? and (2) Do the reliability and validity vary by selected maternal characteristics and birth outcomes as suggested by previous research?¹⁷     

Rates of hospital visits for assault during pregnancy and the year postpartum: timing matters

ObjectiveTo clarify the risk of violence for women during pregnancy and the first year postpartum, we examined the timing of hospital visits for assault among a population cohort of women in Massachusetts.MethodsUsing linked natality and hospital data from 2001 through 2007 for Massachusetts, we examined the timing of hospital (i.e., emergency, inpatient, and observation) visits for maternal assault during seven time periods: the three prenatal trimesters and four three-month postpartum periods. To describe the risk of assault for each of the time periods, we calculated the rate as the number of such visits per 100,000 person-weeks. We used the denominator of 100,000 person-weeks to adjust for variable lengths of gestation and for postpartum periods shortened by subsequent pregnancies.ResultsRates of hospital visits for maternal assault were highest in the first trimester and lowest in the third trimester, with rates of 16.0 and 5.8 per 100,000 person-weeks, respectively. The four postpartum period rates were higher than the third trimester rate but never reached the levels observed in the first and second trimesters.ConclusionsThese findings suggest a changing rate for assault visits during each prenatal trimester and postpartum period. In addition, the importance of violence prevention strategies as part of women''s health care across the life span and the need for preconception care initiatives are reaffirmed.Some studies have shown that violence increases during pregnancy while others have not,^1–4 with variations in findings attributed to differences in definition, assessment, and study design.^3,5 Estimates of the prevalence of violence during pregnancy^6–14 vary from 1% to 20% for the prepregnancy period and from 3.2% to 8.7% for the postpartum periods.^6–8,11 Several studies of violence against pregnant women have focused solely on intimate partner violence, while others have not specified the relationship of the perpetrator to the victim or found that the majority of perpetrators were intimate partners.^8,9Unfortunately, studies of violence that have compared pregnancy with time frames before or after pregnancy have not adjusted for different lengths of observation or examined different risk periods within pregnancy or after delivery through the first year postpartum.^6–8 None of these studies used linked population data to capture visits for assault occurring in multiple emergency departments (EDs) and inpatient hospitals that may differ from the delivery hospital. The majority of previous studies on intentional injury in pregnancy and postpartum relied on retrospective self-reported information and did not collect information at the time of the injury and follow women until the end of the first year postpartum. Understanding differing risk during pregnancy and postpartum can assist violence prevention strategies in clinical care as well as in the community.In Massachusetts from 2001 to 2003, 1% of all women with a live birth or fetal death at ≥20 weeks of gestation (or ≥350 grams) had a hospital visit for assault during pregnancy or in the year postpartum.¹⁵ To clarify the risk of violence in the time around pregnancy, we examined the timing of hospital visits for assault during pregnancy and the first year postpartum among Massachusetts women and calculated the rate of hospital visits for assault per person-weeks of pregnancy. Information about the timing of assaults can help inform prevention strategies.     

Estimating the Size and Cost of the STD Prevention Services Safety Net

The Patient Protection and Affordable Care Act is expected to reduce the number of uninsured people in the United States during the next eight years, but more than 10% are expected to remain uninsured. Uninsured people are one of the main populations using publicly funded safety net sexually transmitted disease (STD) prevention services. Estimating the proportion of the uninsured population expected to need STD services could help identify the potential demand for safety net STD services and improve program planning. In 2013, an estimated 8.27 million people met the criteria for being in need of STD services. In 2023, 4.70 million uninsured people are expected to meet the criteria for being in need of STD services. As an example, the cost in 2014 U.S. dollars of providing chlamydia screening to these people was an estimated $271.1 million in 2013 and is estimated to be $153.8 million in 2023. A substantial need will continue to exist for safety net STD prevention services in coming years.The Patient Protection and Affordable Care Act is expected to increase the number of people in the United States with health insurance during the next eight years,¹ partly by expanding access to Medicaid² and creating health insurance marketplaces.³ However, insurance coverage is not expected to reach 100% of the population.¹ Although the Affordable Care Act provides premium subsidies for those who are at 400% of the federal poverty level⁴ and allows for dependent coverage up to 26 years of age,⁵ some factors that have limited insurance coverage in the past will still be present, to some degree. For example, cost may be a barrier, even with subsidies. A 2009 survey found that 48% of those who are uninsured cited cost as a reason for not having health coverage.⁶ People who are uninsured and have to pay for their care may be more likely to seek low- or no-cost options for care.Studies have shown that patients who seek care at sexually transmitted disease (STD) clinics have lower incomes than the general population, are less likely to have health insurance, and have cited low cost of care as an important reason for presenting to STD clinics.^7–9 Furthermore, cost has been cited as an important reason for choosing care at STD clinics, and the imposition of fees or copays has been shown to reduce the number of patient visits.^8,10,11 Surveys have shown that many STD clinic patients have insurance, but some STD clinic patients with insurance have reported that they would not be willing to use their insurance due to confidentiality concerns.^8,9 From 2002 to 2006–2010, receipt of STD services among U.S. women increased among most subpopulations, with the exception of uninsured women.¹² These factors suggest that low- or no-cost STD care may continue to be important for people lacking health insurance or with limited coverage.STDs such as chlamydia are common,¹³ and the U.S. Preventive Services Task Force recommends that sexually active women aged ≤24 years be screened annually for chlamydia.¹⁴ The Centers for Disease Control and Prevention (CDC) additionally recommends chlamydia screening for all pregnant women regardless of age, annually for men who have sex with men, and for people newly diagnosed with human immunodeficiency virus infection.¹⁵ Although there are no other guidelines for chlamydia screening in men, having multiple sex partners is a risk factor for infection and repeat infection.^15–17 For both men and women diagnosed with chlamydia, CDC recommends repeat screening three months after treatment.¹⁵Given the changes in the health-care landscape in the United States, we estimated the size of the uninsured population aged 15–44 years in need of STD services based on existing clinical guidelines or elevated STD risk. To estimate a lower bound of the cost of providing STD services to the population in need of services, we estimated the annual cost of chlamydia screening, diagnostic testing, treatment, and repeat testing from 2013–2023 according to CDC guidelines.     

Area-Level Socioeconomic Disadvantage and Severe Pulmonary Tuberculosis: U.S., 2000–2008

Objectives

Lower socioeconomic status (SES) is associated with increased risk of tuberculosis (TB) and diagnostic delays, but the extent to which this association reflects an underlying gradient in advanced status of pulmonary TB is unknown. We conducted a multilevel retrospective cohort analysis examining the relationship between socioeconomic characteristics and pulmonary TB disease status, as measured via sputum smears and chest radiography results.

Methods

We included 862 incident TB patients reported in King County, Washington, from 2000–2008. We abstracted patient-level measures from charts and surveillance data. We obtained socioeconomic characteristics of TB patients, as well as those of the areas where TB patients lived, from the 2000 U.S. Census. A socioeconomic position (SEP) index was derived to measure SES.

Results

Of those with known results, 814 of 849 patients (96%) displayed abnormal radiography findings. A total of 239 graded patients (39%) had positive smears, 136 (57%) of whom had grades of moderate (3+) or numerous (4+) acid-fast bacilli. In unadjusted analyses, patients living in lower SEP areas did not appear to have higher probabilities of more advanced disease. In multivariate models adjusting for individual demographic and socioeconomic measures, as well as area-based demographic variables, block-group SEP was not significantly associated with more advanced pulmonary disease.

Conclusions

Lower SEP was not significantly associated with greater pulmonary disease severity after controlling for individual age, race, sex, and origin, and block-group race, ethnicity, and origin. These findings suggest that the severity of pulmonary TB at diagnosis is not synonymous with delayed diagnosis.Although tuberculosis (TB) incidence continues to decline in the United States, the proportion of advanced pulmonary TB, defined as smear-positive or cavitary disease, has been increasing.^1,2 Advanced clinical presentation may result from delayed diagnosis and treatment and may lead to greater infectivity and likelihood of transmission within a community.^3,4Lower socioeconomic status (SES) has been linked to more severe disease status for a variety of diseases including cystic fibrosis,⁵ sarcoidosis,⁶ subclinical coronary heart disease,⁷ cancers,^8,9 and pulmonary fibrosis.¹⁰ While the presence of other comorbidities, poor access to care, substance abuse, low income, education level, and lack of insurance^11–16 constitute risk factors for delays in TB diagnosis, little work has been done to characterize the association between SES and advanced pulmonary TB disease, as more advanced disease is often seen as characteristic of diagnostic delay. Furthermore, much of the work examining diagnostic delay has been examined outside the U.S. Areas in which people live are likely to have differential access to care, including proximity, cost, and presence of public clinics and transportation.^17,18 Disease status is likely to be impacted by such variations in area-level factors and, in particular, by variations in area-level SES across neighborhoods.Using TB case registry data on incident TB patients combined with chart reviews, we explored the relationship between individual patient demographic and SES attributes, in combination with area-level social characteristics, and two TB severity outcomes at diagnosis—lung cavitation and smear-positive acid-fast bacilli (AFB) in sputum smears. These measures have been linked to impaired pulmonary function, TB treatment failure, or death^19,20 and represent later disease stages.^21,22Specifically, this study was designed to assess whether severity of pulmonary TB disease was positively associated with area-based socioeconomic disadvantage within King County, Washington. By examining socioeconomic and demographic characteristics of block groups, our hope was to identify those factors that might play an important role in predicting disease severity at diagnosis. Such findings could provide insight into pathways by which area-level SES independently affects pulmonary disease severity.     

Evaluation of a Community Health Worker Intervention to Reduce HIV/AIDS Stigma and Increase HIV Testing Among Underserved Latinos in the Southwestern U.S.

Objectives

Latinos are at an elevated risk for HIV infection. Continued HIV/AIDS stigma presents barriers to HIV testing and affects the quality of life of HIV-positive individuals, yet few interventions addressing HIV/AIDS stigma have been developed for Latinos.

Methods

An intervention led by community health workers (promotores de salud, or promotores) targeting underserved Latinos in three southwestern U.S. communities was developed to decrease HIV/AIDS stigma and increase HIV knowledge and perception of risk. The intervention was led by HIV-positive and HIV-affected (i.e., those who have, or have had, a close family member or friend with HIV/AIDS) promotores, who delivered interactive group-based educational sessions to groups of Latinos in Spanish and English. To decrease stigma and motivate behavioral and attitudinal change, the educational sessions emphasized positive Latino cultural values and community assets. The participant pool comprised 579 Latino adults recruited in El Paso, Texas (n=204); San Ysidro, California (n=175); and Los Angeles, California (n=200).

Results

From pretest to posttest, HIV/AIDS stigma scores decreased significantly (p<0.001). Significant increases were observed in HIV/AIDS knowledge (p<0.001), willingness to discuss HIV/AIDS with one''s sexual partner (p<0.001), and HIV risk perception (p=0.006). Willingness to test for HIV in the three months following the intervention did not increase. Women demonstrated a greater reduction in HIV/AIDS stigma scores when compared with their male counterparts, which may have been related to a greater increase in HIV/AIDS knowledge scores (p=0.016 and p=0.007, respectively).

Conclusion

Promotores interventions to reduce HIV/AIDS stigma and increase HIV-related knowledge, perception of risk, and willingness to discuss sexual risk with partners show promise in reaching underserved Latino communities.Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) has disproportionately affected U.S. Latinos during the last 25 years. Although Latinos constitute 16% of the U.S. population, they account for 19% of those living with HIV and 21% of new HIV infections.¹ Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended HIV testing for all people aged 13–64 years.² However, nearly half (46%) of Latino adults aged 18–64 years have never been tested, compared with 23% of black and 50% of white adults.³ Additionally, HIV testing often occurs at a late stage among HIV-positive Latinos. More than one-third (36%) of HIV-positive Latinos were diagnosed with AIDS within one year of learning their HIV status, compared with 32% of white people and 31% of black people.³ Late HIV testing hinders treatment options and may contribute to unknowing HIV transmission.Factors contributing to low HIV testing rates among Latinos include poverty, lack of health-care access, and limited availability of culturally and linguistically responsive services.^1,4–6 HIV/AIDS stigma is another factor.^7,8 UNAIDS (Joint United Nations Programme on AIDS) defines HIV stigma as the “devaluation of people either living with or associated with HIV/AIDS.”⁹ Stigma often results from fears about HIV as well as the associations of HIV with stigmatized groups such as homosexuals, sex workers, and injection drug users.^9,10HIV/AIDS stigma has negative consequences both at a population level and for individuals who are its targets, including people living with HIV/AIDS. Stigmatizing attitudes toward people living with HIV/AIDS are associated with decreased HIV testing, limited utilization of HIV prevention services, and high-risk sexual behaviors.^7,10,11 Additionally, for people living with HIV/AIDS, the stigma associated with HIV/AIDS contributes to unwillingness to disclose HIV status, unsafe sexual behaviors, delays in care seeking, reduced treatment adherence, mental health issues, and difficulties obtaining social support.^9,11–14Despite significant implications, few interventions have been developed to reduce HIV/AIDS stigma.^10,11,15 Existing interventions have often focused on specific populations (e.g., university students and health-care providers), with few interventions focused on Latinos,^11,15,16 who have high levels of stigmatizing attitudes toward people living with HIV/AIDS^1,17,18 that contribute to negative outcomes.^7,19Among Latinos, research indicates that community health workers (promotores de salud, hereinafter “promotores”) are an effective and culturally acceptable means of reaching the population with health information and motivating health behaviors.^20,21 Promotores are well positioned to promote changes in their communities because they share language and cultural values, are held in high esteem, and are perceived as role models.²¹ Promotores have been used to address health conditions ranging from chronic diseases to preventive screenings.^20–22 Several interventions have incorporated promotores into HIV prevention, finding significant changes in HIV risk behaviors, HIV counseling and testing, and other psychosocial constructs important to prevention.^16,23–29 To date, few studies have used promotores in interventions to reduce HIV stigma among Latinos.¹⁶We describe and report findings of an intervention using promotores to reduce HIV/AIDS stigma and increase willingness to seek HIV testing among Latinos in three communities in the southwestern United States: Los Angeles, California; San Ysidro, California; and El Paso, Texas.     

What Predicts Dissemination Efforts Among Public Health Researchers in the United States?

Objectives

We identified factors related to dissemination efforts by researchers to non-research audiences to reduce the gap between research generation and uptake in public health practice.

Methods

We conducted a cross-sectional study of 266 researchers at universities, the National Institutes of Health (NIH), and CDC. We identified scientists using a search of public health journals and lists from government-sponsored research. The scientists completed a 35-item online survey in 2012. Using multivariable logistic regression, we compared self-rated effort to disseminate findings to non-research audiences (excellent/good vs. poor) across predictor variables in three categories: perceptions or reasons to disseminate, perceived expectation by employer/funders, and professional training and experience.

Results

One-third of researchers rated their dissemination efforts as poor. Many factors were significantly related to whether a researcher rated him/herself as excellent/good, including obligation to disseminate findings (odds ratio [OR] = 2.7, 95% confidence interval [CI] 1.1, 6.8), dissemination important for their department (OR=2.3, 95% CI 1.2, 4.5), dissemination expected by employer (OR=2.0, 95% CI 1.2, 3.2) or by funder (OR=2.1, 95% CI 1.3, 3.2), previous work in a practice/policy setting (OR=4.4, 95% CI 2.1, 9.3), and university researchers with Prevention Research Center affiliation vs. NIH researchers (OR=4.7, 95% CI 1.4, 15.7). With all variables in the model, dissemination expected by funder (OR=2.0, 95% CI 1.2, 3.1) and previous work in a practice/policy setting (OR=3.5, OR 1.7, 7.1) remained significant.

Conclusions

These findings support the need for structural changes to the system, including funding agency priorities and participation of researchers in practice- and policy-based experiences, which may enhance efforts to disseminate by researchers.Significant investment is put toward research in public health. Ideally, the findings of this investment should improve public health practice.^1–5 Unfortunately, there is a lingering gap between research and practice.^6–10 Glasgow and Emmons identified barriers to translation of research findings into practice, such as research programs not being “packaged or manualized” for ease of implementation nor including adequate information for adapting implementation materials.⁶ The barriers have been attributed to a lack of fit between interventions and the settings in which they are implemented, as well as the information provided by the researcher and that needed by the practitioner tasked with implementation.^6,11,12 The lack of fit stems, in part, from a lack of emphasis among researchers on creating resources aimed at practitioners to ensure that the products of their research are disseminated.^6,13Many factors may influence the extent to which researchers disseminate their findings to non-research audiences.^8,11,13–15 These factors include lack of capacity among practitioners to apply research evidence, lack of practice experience among academics, lack of priority in the published literature for effectiveness and dissemination research, and, importantly, limited funds for dissemination.¹³ Another influential factor could be a lack of priority on dissemination for individual researchers and their academic settings.¹⁴ This disconnect could also stem from broader, system-wide factors such as funding structures, which contribute to less-than-optimal dissemination.^14,16,17Because numerous barriers to dissemination exist at multiple levels, there is also a gradient of options to enhance and encourage such efforts (e.g., designing for dissemination, training in dissemination, and implementation research) that fall along a spectrum of efforts to promote and enhance the capacity of researchers to disseminate findings.^14,17,18 The feasibility of these options, particularly regarding those at structural and setting levels, is accordingly variable. It is therefore important to identify malleable factors within the system to suggest feasible approaches to enhancing dissemination efforts. These factors are both at the individual researcher level, such as having had practice-based work experience, and at the system level, including funding opportunities. Few studies have explored factors associated with research dissemination efforts in large samples that cross settings. We aimed to identify factors related to public health researchers'' self-rated excellence in dissemination of research findings to non-research audiences.